The Despicable Patient and Name Calling

How does a physician deal with a despicable patient—not just a difficult patient, but an individual whose maladaptive behavior reaches the extremes of physical and verbal abuse, persistent sexual harassment, and even danger to medical staff or the patient’s family members? The answers lie on two levels, professional and personal.

Professionally, techniques such as boundary- and limit-setting, an empathetic demeanor, obtaining additional staff for security and chaperoning purposes, careful monitoring and documentation of clinical encounters, and reasonable attempts to develop a therapeutic alliance are likely to help the physician navigate encounters with even the most behaviorally challenging patients.

However, on a personal level, the answers are less clear. How does one face regular exposure to some of the ugliest facets of human behavior and maintain sanity? Many, if not most, physicians employ defense mechanisms, and humor is high on the list. In the humor category some unofficial acronyms have emerged, some of which are not intended to be derogatory but are clearly inappropriate for professional settings or patient encounters. Examples include FLK (funny-looking kid) and LOL (little old lady).

A recent Slate article by Columbia University psychiatrist Anne Skomorowsky looks at one of those acronyms, exploring the author’s experiences with it and exposing it to the general public. The abbreviation: SHPOS, standing for “subhuman piece of shit.” The author discusses the acronym as one commonly used by physicians for patients they despise or who behave disgracefully. She describes encounters with patients who displayed severely dysfunctional behavior, such as harassing medical staff or endangering themselves, staff, and family members; she discussed her own intense reactions to those patients, as well as the misogynistic components to the behavior. Dr. Skomorowsky additionally explains that the term has been in use since at least the early 1980s and is “known to physicians everywhere.” She concludes that “[n]o one is proud to call another person subhuman.”

Dr. Skomorowsky is certainly correct that the despicable patient does exist. A recent discussion of her article on Sermo confirms that physicians from nearly all specialties have had similar encounters. Maladaptive, misogynistic, abusive, infuriating, assaultive, and dangerous behavior is not confined to the psychiatry ward, and it cannot be tolerated in a therapeutic setting. SHPOS may reflect “the clash of various narcissistic needs between the resident and his difficult patient,” in the words of Strauss (South Med J 1983; 76: 981-984). SHPOS also goes too far, is not in common usage and carries overtones of arrogance and lack of sympathy by the medical profession.

Why is SHPOS an unjustifiable acronym? Despicable behavior is an element of the human condition. The behavioral range of our species is vast and ranges from the most noble to the most base. The “SHPOS” is as human, and as “subhuman,” as are we in the white coats. Though physicians, professionally and often personally, aim for the noble end of the human behavioral spectrum, members of our profession have committed terrible acts against mankind, their patients, or their families. We are not above reproach and must not rejoice in a false sense of superiority. Superiority is at the heart of the abbreviation SHPOS, which labels the wrongdoer as something less than human; his behavior is explained by his inferiority. When confronted with what seems to be a SHPOS, we are looking at one of our own kind.

The Slate article brought back a memory from the very beginning of my medical education. Stephen Lefrak, MD, Professor of Medicine at Washington University School of Medicine, delivered the address at the White Coat Ceremony on my first day as a medical student. He recounted a story from early in his own training, during which he assisted a Jewish surgeon and Holocaust survivor in a procedure to save the life of a patient. As the procedure was getting underway, Lefrak noticed that the patient was tattooed with swastikas and other neo-Nazi insignias. He asked his colleague whether that patient deserved their efforts. The Holocaust survivor’s response was that to give any less than their best effort would be sinking to the patient’s level.

That ethos is what makes medicine special—a calling—and provides the glue of the doctor-patient relationship. Medical care is nonjudgmental. To be repulsed by despicable behavior is only natural, but to denigrate patients behind their backs erodes the central compassionate culture of the medical profession. The vast majority of doctors do not engage in the denigration of patients. A poll on Sermo (with more than 2500 responses at the time of writing) revealed that 90% of physicians had never heard the acronym SHPOS. We may occasionally have (justified) unspeakable thoughts in response to despicable behavior, but perhaps that is how those thoughts should remain. As one physician on Sermo said, “but when you let it out your lips, others hear you. It makes you look bad.” To call the offender subhuman is a facile defense mechanism, but for our good fortune we do not walk in his shoes. To call him a SHPOS is to be judgmental and be drawn into despicable behavior ourselves.